MGVFC Membership Application

What Type of Membership are you Applying for?*
Name
First Middle Last
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
How long at current address?*
Phone Number*
Gender*
Date of Birth*
Month
Day
Year
Your Age*
Are you currently employed?*
- Yes
- No
Where are you employed?*
Have you ever been convicted of a traffic offense, misdemeanor, or felony?*
- No, I have not been convicted of anything
- Yes, Traffic Offense
- Yes, Misdemeanor
- Yes, Felony
Please list the charge, jurisdiction, and disposition.*
Have you ever been a member of any other Fire or EMS organization?*
- Yes
- No
Which Fire or EMS Organization?*
More than one? Please use the "+" sign to add.
Organization Name Years Served
Please list any Fire or EMS certifications you currently hold.
One certificate per line, please use the "+" sign to add more.
References
Please provide two references can not use family members
Reference #1 Relationship*
Reference #1 Name*
First Last
Reference 1 Phone*
Reference #1 Email*
Reference #2 Relationship*
Reference #2 Name*
First Last
Reference #2 Phone*
Reference 2 Email*
Decleration #1*
I the undersigned, certify by my initals that I have read and fully comprehend this form in it's entirety and that the information herein provided is true and complete to the best of my knowledge. I understand that, should any statement I have made prove to be false, misleading or erroneous, it may result in the rejection of my application or my discharge from the Maugansville Goodwill Volunteer Fire Company.
Comments
This field is for validation purposes and should be left unchanged.

MAUGANSVILLE

GOODWILL VOLUNTEER FIRE COMPANY

We Look Forward to Having you Join our Family

References

MAUGANSVILLE GOODWILL VOLUNTEER FIRE COMPANY

Phone

Organization Name	Years Served